Failures in the Respectful Care of Critically Ill Patients

Abstract

Background: The emotional toll of critical illness on patients and their families can be profound and is emerging as an important target for value improvement. One source of emotional harm to patients and families may be care perceived as inadequately respectful. The prevalence and risk factors for types of emotional harms is under-studied.

Methods: This prospective cohort study was conducted in nine ICUs at a tertiary care academic medical center in the United States. Prevalence of inadequate respect for (a) the patient and (b) the family, as well as prevalence of perceived lack of control over the care of their loved ones, was assessed by the Family Satisfaction with Care in the Intensive Care Unit instrument. The relationship between these outcomes with demographic and clinical covariates was assessed. Stratification by patient survivorship was performed in sensitivity analysis.

Results: Of more than 1,500 respondents, 16.9% and 21.8% reported that the patient or the family member, respectively, received inadequate respect. No clinical characteristics of the patients were associated with inadequate respect for either the patient or the family member. By comparison, more than half of respondents reported a lack of control over their loved one's care; this finding was associated with multiple clinical factors. Prevalence and associated factors differed by patient survivorship status.

Conclusion: Care that is inadequately respectful to patients and families in the setting of critical illness is prevalent but does not appear to be associated with clinical characteristics. The incidence of such emotional harms is nuanced, difficult to predict, and deserves further investigation.

Figure 1:

Univariable analysis shows no association between either inadequate respect for the patient (Figure 1a) or inadequate respect for the family member (Figure 1b) and clinical factors. Adult children of patients are more likely to report both inadequate respect for the patient (odds ratio [OR], 1.34; 95% confidence interval [CI] = 1.01–1.79) and inadequate respect for the family member (OR, 1.38; 95% CI = 1.06–1.78). Black squares represent ORs; error bars represent 95% CIs. RAS, Richmond Agitation-Sedation Scale; pt, patient.

Figure 1:

Univariable analysis shows no association between either inadequate respect for the patient (Figure 1a) or inadequate respect for the family member (Figure 1b) and clinical factors. Adult children of patients are more likely to report both inadequate respect for the patient (odds ratio [OR], 1.34; 95% confidence interval [CI] = 1.01–1.79) and inadequate respect for the family member (OR, 1.38; 95% CI = 1.06–1.78). Black squares represent ORs; error bars represent 95% CIs. RAS, Richmond Agitation-Sedation Scale; pt, patient.

Figure 2:

Families reported higher levels of control when the patient was cared for by a primary medical ICU team (adjusted odds ratio [AOR], 1.3; 95% confidence interval [CI] = 1.1–1.7) or by a team staffed by residents (AOR, 1.6; 95% CI = 1.12.3), or if the patient received any life-support therapies—defined as use of either mechanical ventilation, vasopressors, or initiation of dialysis—(AOR, 1.6, 95% CI 1.3–2.1). Odds ratios are adjusted for other variables presented as well as for sex of patient and proxy, and type of relative. Black squares represent AORs; error bars represent 95% CIs.

Figure 3:

Inadequate respect for the patient was more frequently reported by family members of nonsurvivors (19.4% family of nonsurvivors vs. 14.4% family of survivors; p = 0.01). Rates of reported inadequate respect for the family did not differ by survival status (22.6% family of nonsurvivors vs. 21.1% family of survivors; p = 0.50). Family members of nonsurvivors were less likely to report a lack of control for their loved one (42.5% family of nonsurvivors vs. 67.8% family of survivors; p < 0.001). Black squares represent adjusted odds ratios; error bars represent 95% confidence intervals